Accepted Manuscript

Title: Exposure Therapy for Emetophobia: A Case study withThree-Year Follow-Up

Author: Danielle J. Maack Brett J. Deacon Mimi Zhao

PII: S0887-6185(13)00133-3DOI: http://dx.doi.org/doi:10.1016/j.janxdis.2013.07.001Reference: ANXDIS 1522

To appear in: Journal of Anxiety Disorders

Received date: 15-1-2013Revised date: 12-5-2013Accepted date: 8-7-2013

Please cite this article as: Maack, D. J., Deacon, B. J., & Zhao, M., Exposure Therapy forEmetophobia: A Case study with Three-Year Follow-Up, Journal of Anxiety Disorders(2013), http://dx.doi.org/10.1016/j.janxdis.2013.07.001

This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.

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AbstractEmetophobia, also referred to as a specific phobia of vomiting, is a largely under-researched and poorly understood disorder with prevalence estimates of ranging between 1.7 and 3.1% for men and 6 and 7% for women (Hunter & Antony, 2009; Philips, 1985). The current case study, therefore, sought to methodically apply exposure-based behavioral treatment to the treatment of a 26 year-old, Hispanic, female suffering from emetophobia. Although not as powerful as a randomized design, this description may still add to the existing emetophobia literature through the illustration of adaptation of published behavioral treatments for other specific phobias. The case presented was successful in terms of outcome, and includes a three-year follow up wherein treatment gains were measurably maintained.

Keywords: emetophobia; phobia; vomiting; exposure therapy

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Exposure Therapy for Emetophobia

Highlights

Emetophobia, a specific phobia of vomiting, is an under-researched and poorly

understood anxiety disorder.

This case study outlines the assessment, conceptualization and treatment of an individual

with emetophobia.

The utility of exposure therapy, with gains maintained at three-year follow-up is

demonstrated.

*Highlights (for review)

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Exposure Therapy for Emetophobia 1

RUNNING HEAD: EXPOSURE THERAPY FOR EMOTOPHOBIA

Exposure Therapy for Emetophobia: A Case study with Three-Year Follow-Up

Danielle J. Maacka

Brett J. Deaconb

Mimi Zhaoa

aUniversity of Mississippi

Department of Psychology

205 Peabody Building

University, MS 38677

bUniversity of Wyoming

Department of Psychology, Dept. 3415

1000 E University Ave

Laramie, WY 820711000

Address correspondence to: Danielle J. Maack, Department of Psychology, University of

Mississippi 205 Peabody Building , University , MS 38677; Phone: (662) 915-1775; Fax: (601)

915-5398; E-mail: djmaack@olemiss.edu

*Manuscript

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Exposure Therapy for Emetophobia 2

Exposure Therapy for Emetophobia: A Case study with Three-Year Follow-Up

1. Introduction

Emetophobia, a specific phobia of vomiting, is an under-researched and poorly

understood anxiety disorder (Boschen, 2007; Marks, 1987; van Hout & Bouman, 2012; Veale &

Lambrou, 2006). Prevalence estimates of emetophobia range between 1.7 and 3.1% for men and

6 and 7% for women (Hunter & Antony, 2009; Philips, 1985), yet few empirical data are

available regarding this specific disorder. Emetophobia is considered to be a chronic problem

with early onset (Lipsitz, Fyer, Paterniti, & Klein, 2001), and it often produces clinically

significant distress and impairment in social and other areas of functioning.

Fear of vomiting can be triggered by both internal and external stimuli such as sight of

another person vomiting, nausea, or concerns with contaminated food. Most individuals with

emetophobia tend to avoid stimuli associated with vomiting such as eating specific foods,

strenuous exercise, and drinking alcoholic beverages (van Hout & Bouman, 2012; Veale &

Lambrou, 2006). Other research also supports the notion that triggering stimuli are diverse, with

previously demonstrated cues ranging from the more innocuous and cognitive (e.g., hearing or

seeing the word “vomit”) to the more behavioral and contextual (e.g., eating in public, which

precipitates a fear of becoming nauseous; Lipsitz et al., 2001; Veale & Lambrou, 2006). In the

limited research that exists it has also been noted that these cues result in potentially serious

behavioral sequelae; for example, 44% of all female emeotphobics from an online survey

reported that they avoid or delay becoming pregnant (Lipsitz et al, 2001).

Although relatively little is known about this phobia, preliminary research suggests that it

is not a rare condition seen in clinical practice (van Hout & Bouman, 2012), and as such warrants

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Exposure Therapy for Emetophobia 3

further attention. With its documented course as chronic, with an early onset, along with

different manifestations in presentation (van Hout & Bouman, 2012), the overall

conceptualization of emetophobia is in its early stages. The paucity of attention to this disorder

may be exacerbated by clinicians’ anecdotal impressions of emetophobia as a difficult disorder

to treat, as elucidated by previous surveys that cited high dropout and poor treatment response

(Veale & Lambrou, 2006). Additionally, there are no randomized controlled trials (RCTs)

examining treatment approaches for this disorder; in fact, few developed treatment models for

this type of specific phobia exist without consideration of level of scientific examination or

empirical support (see Boschen, 2007). As such, treatment of emetophobia continues to be

unstandardized, although several therapeutic approaches have been employed to mixed results,

including the following: hypnotherapy (McKenzie, 1994; Ritow, 1979), imaginal coping (Moran

& Obrien, 2005), interoceptive exposure and “analogue vomiting” (McFadyen & Wyness, 1983),

and psychotropic medication (Lipsitz et al., 2001).

There is substantial support for exposure therapy as a highly effective treatment for a number

of specific phobias including animal phobia (Bandura et al., 1969; Gilroy et al., 2000; Gotestam

and Hokstad, 2002), claustrophobia (Booth & Rachman, 1992; Ost et al., 2001), flying phobia

(Walder, McCraken, Herbert, James, & Brewitt, 1987), and height phobia and driving phobia

(Williams, Dooseman, & Kleinfield, 1984). From the limited research regarding emetophobia,

specifically what is known about maladaptive beliefs and safety behaviors suggests that it

presents much like other phobias and would likely respond to the same exposure-based treatment

approach known to work well for phobias in general. Existing treatment studies (i.e. case studies)

are few in number, as previously mentioned, and have generally examined treatment approaches

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Exposure Therapy for Emetophobia 4

disparate from what has been demonstrated to work in the treatment of other specific phobias

(i.e., exposure).

2. Present Study

The current case study, therefore, sought to methodically apply exposure-based behavioral

treatment to the treatment of a young woman suffering from emetophobia. Although not as

powerful as a randomized design, this description may still add to the existing emetophobia

literature through the illustration of adaptation of published behavioral treatments for other

specific phobias. The case presented was successful in terms of outcome, and includes a three-

year follow up wherein treatment gains were measurably maintained.

2.1 Client Information

“Lindsey” (a pseudonym) presented to an outpatient university-based psychology clinic

as a 28 year old, single, Catholic, Hispanic female. She completed a high school education and

was living with her partner in a small rural, western town. She was referred by a community

mental health provider specifically for treatment of emetophobia in January of 2007. Consent for

treatment was obtained prior to beginning services, and she subsequently provided her separate,

explicit consent to have her case presented for publication.

2.11 Presenting Complaints/History of Problem

Lindsey’s primary presenting problem was emetophobia. She reported that she wanted to

become pregnant and start a family with her fiancé, but that she was unable to attempt to

conceive due to apprehension and fear about the possibility of experiencing morning sickness

(and thus vomiting). She explained that if she were to conceive her morning sickness might

cause her to vomit, and she would likely choke on the vomit and subsequently die. Lindsey also

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Exposure Therapy for Emetophobia 5

indicated experiencing intrusive images and thoughts surrounding vomiting. She stated that when

she thought about vomiting, she felt as if she were choking or suffocating, and that if she

vomited she might swallow her tongue, which would be fatal. She reported experiencing these

thoughts when encountering stimuli reminiscent of vomiting (e.g., seeing or hearing others vomit

or gag). She stated that she had not vomited since the 6th

grade at which time she endured a

“traumatic vomiting experience.” She said that she came home sick from school, and at one point

ran to the bathroom and proceeded to repeatedly vomit. During this time, she began to choke on

pieces of the expectorant and felt as though she was going to die. Since this time, she reported

continuous rumination about this experience, and as such, at the beginning of treatment she

endorsed being hypervigilant to any cues or stomach sensations that might be associated with

vomiting. She indicated that she had explicitly trained herself for this avoidance over a long

period of time in order to prevent herself from vomiting or being in a situation where she could

possibly vomit. When asked, she reported that her “gut” feeling was that there was a 50% chance

she would die if she were to throw up, although she also stated that logically, the chance of death

was more likely in the range of 10%.

Lindsey stated that the clinically significant impact of emetophobia was the avoidance of

becoming pregnant. She said that until she could believe she would be able to deal with morning

sickness without the fear or ultimate outcome of death, she would not actively attempt to become

pregnant. Additionally, as a secondary goal/concern, she reported that she would like to be able

to be supportive of others (i.e. her fiancé, family, friends) when they were sick. She stated that in

the month prior to presenting for treatment her fiancé was sick and vomiting, but she was unable

to help. Instead, she reported plugging her ears and staying away from him as much as possible,

which was consistent with her reported avoidance of cues associated with vomiting. She also

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Exposure Therapy for Emetophobia 6

stated that she revolved her daily routine around heightened sensitivity to her stomach issues,

which resulted in routine avoidance of many other activities including: exercise, amusement park

rides, cooking chicken at home, and drinking alcohol, all of which led to a constant monitoring

of any symptoms related to nausea. On rare occasions that Lindsey chose to engage in these

activities, she reported always being careful to constrain her behavior such that she did not eat

anything beforehand. Additionally, she indicated that she carried antacid tablets with her at all

time, for use in the event that her stomach felt disrupted.

Lindsey reported previously seeking treatment for emetophobia with no symptom

alleviation. Her accounting of the nature of this previous treatment included a diverse array of

approaches, including: Eye Movement Desensitization Reprocessing, hypnotherapy, various

forms of pharmacotherapy, and an unspecified “talk therapy.” She reported that although

prescription medications appeared to be of benefit for relief of symptoms of depression, OCD

and Tourettes, no type of therapy (pharmacotherapy, psychotherapy or other) to date had been

effective in touching the emetophobic symptoms. Additionally, Lindsey reported consistent

attendance and adhering to treatment protocols; however, she reported continued difficulty with

the experience of emetophobia.

3. Initial Assessment

As part of the intake session (3.25 hours) at a University-based psychological treatment

center the Mini International Neuropsychiatric Interview- 5th

edition (M.I.N.I.-5; Sheehan et al.,

2002) was administered. In addition, Lindsey completed a number of self-report measures of

broad psychiatric symptoms (see Table 1). The assessment and direct treatment of this client was

concurrently provided by both a Master’s level graduate student and the supervising

psychologist.

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Exposure Therapy for Emetophobia 7

3.1 Measures related to emetophobia, differential diagnosis and symptoms

The Anxiety Sensitivity Index – 3 (ASI-3; Taylor et al., 2007) is an 18-item measure

constructed to assess an individual’s fear of arousal-related sensations that arise from the belief

that these sensations may have adverse consequences (i.e., anxiety sensitivity; Reiss & McNally,

1985). Items are rated on a 5-point Likert-type scale from 0 = very little to 4 = very much. The

ASI-3 measures three theoretically derived facets of anxiety sensitivity: physical (e.g., “It scares

me when my heart beats rapidly”), cognitive (e.g., “When I feel “spacey” or spaced out, I worry

that I may be mentally ill”), and social concerns (e.g., “It is important not to appear nervous”).

Initial validation of the ASI-3 demonstrated that the instrument possessed sound psychometric

properties as examined across a number of sites using diverse participants (Taylor et al., 2007).

For this questionnaire, Lindsey reported that she answered in a manner as to her experience when

thinking about vomiting.

The Obsessive Compulsive Inventory- Revised (Foa, et al. 2002) is an 18 item self-report

measure assessing distress associated with obsessions and compulsions. The scale has reported

good internal consistency (.88), adequate test-retest reliability (.70), and good discriminant

validity between anxiety disorders and non-anxious controls (Hajcak, Huppert, Simons, & Foa,

2004).

The Body Vigilance Scale (BVS; Schmidt et al., 1997) measures the tendency to attend to

panic-related body sensations. The measure consists of four items The BVS measures the

tendency to attend to panic-related body sensations. The measure consists of four items; three

assess the degree of attentional focus, perceived sensitivity to changes in bodily sensations and

time spent on average attending to bodily sensations. The fourth item involves specific ratings

for attention to 15 different bodily sensations. The BVS has demonstrated good internal

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Exposure Therapy for Emetophobia 8

consistency (in students in student αs=.82 and .84), community (α=.82), and adequate 5 week test-

retest reliability (rs = .67 and .69; Schmidt et al., 1997).

3.2 Diagnostic Formulation

Lindsey’s report on the initial interview indicated that she had a history of Tourette’s

Disorder and Obsessive Compulsive Disorder (OCD), both of which were diagnosed when she

was in junior high school. She stated that the symptoms of Tourette’s diminished over time with

the only current, residual symptoms being occasional muscle tension and “sniffling” type of

ticks. However, she mentioned continued concerns of passing these disorders onto her child. She

also reported that her current symptoms of OCD were focused around ordering and symmetry.

She elaborated to explain that if things were out of place in her home, and she was unable to

straighten them it would give her a “just not right” feeling. Specifically, she reported having a

need for the house to be “spotless,” performing “excessive” cleaning, and needing hangers in the

closet to be evenly arranged. Prior to leaving for work in the morning, she indicated that she felt

compelled to double check the stove, lamps, night-lights, and door locks. She denied having a

specific threat forecast if she were unable to complete these tasks; rather, she indicated that she

would ruminate about negative consequences of leaving these appliances running (i.e., “what if

something horrible happens?”) until she checked them or was able to become distracted.

Additionally (and related to differentiating emetophobia from symptoms of OCD) she notably

denied experiencing any contamination fear, obsessions, or compulsive behavioral symptoms

related to her fear of vomiting. Results from the OCD portion of the M.I.N.I.-5 thus confirmed a

current diagnosis of OCD and were helpful in extricating these symptoms from her separate

diagnosis of Specific Phobia, Other Type (i.e., emetophobia; see below).

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Exposure Therapy for Emetophobia 9

Lindsey also reported experiencing panic attacks, which she acknowledged were

associated with concerns about vomiting, and therefore had identifiable triggers. She stated that

last year she experienced 30-50 attacks, some of which were nocturnal. However, she reported

no pressing concerns about having panic attacks, fears of situations that may trigger another

attack, or avoidance of places or situations that could precipitate these experiences. Therefore,

from her history and structured interview, a past, but not current diagnosis of Panic Disorder was

confirmed.

At the time of treatment, Lindsey was reportedly prescribed a tricyclic antidepressant

(amitriptyline, 60mg/qHS). She indicated the medication was prescribed to treat the following:

teeth grinding, sympotoms of Tourette’s Disorder, and depressed mood. Self-report and clinical

interview suggested symptoms of depression were well-managed on this medication. A diagnosis

of Major Depressive Disorder, in full remission was assigned.

In addition to administration of the M.I.N.I.-5, a separate specific phobia module was

also administered to Lindsey. She affirmatively endorsed symptoms indicative of experiencing a

specific phobia with her phobic stimuli being vomiting including: 1) always feeling frightened

when confronted with vomiting (or any related cues); 2) acknowledging this fear was

unreasonable or overstated; 3) always going out of her way to avoid situations where she

potentially could vomit; and 4) endorsing this fear caused significant distress and disrupted

normal daily functioning. In summary, data from the initial assessment suggested that Lindsey’s

current distress and most severe symptoms were best attributed to a diagnosis of Specific Phobia,

Other Type (i.e., emetophobia) with the following co-occurring disorders: OCD, and Major

Depressive Disorder, in full remission. This was consistent with the patient’s reported presenting

problem.

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Exposure Therapy for Emetophobia 10

3.3 Case Conceptualization

Lindsey’s case was conceptualized from a cognitive-behavioral model of emetophobia

(Figure 1). Notably, her affective response to vomit cues was generally increased anxiety, as

opposed to evocation of disgust (i.e. contamination). Specifically, she believed that if she were to

vomit, she would choke and die. She associated a queasy stomach with the need to vomit, which

facilitated to the etiology of her manifest hypervigilance to stomach sensations. When she could

perceive any changes in her stomach’s activity she immediately believed she would vomit and

thus would begin employing safety behaviors (taking antacids, sipping 7-Up, avoiding eating).

The safety behaviors served to decrease her level of anxiety, which in turn reinforced the belief

that these behaviors were what keep her from vomiting and equated to what kept her alive (given

her strong degree of belief in the potential mortality associated with vomiting).

The implementation of these safety behaviors provided a long-term, intensive barrier to

Lindsey’s ability to learn what would happen if she actually did vomit, and thus an inability to

ameliorate her fears on the basis of naturalistic exposure Without this experience and the

concomitant opportunity for emotional processing (Foa & Kozack, 1986) that it could provide, it

was likely that Lindsey would continue. Exposure to less intense situations, such as watching

videos, inducing sensations related to vomiting, simulating vomiting, etc. were not deemed

sufficient to provide her with corrective information regarding her core maladaptive belief (and

were similarly avoided in her naturalistic environment). Additionally, she already knew,

logically, that other people do not choke and subsequently die when vomiting. As with so many

other cases being treated for diffuse disorders, however, she needed to learn this for herself and

“feel” what she already “knew.”

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Exposure Therapy for Emetophobia 11

Using this conceptualization and a broad literature of scientific support, exposure therapy

was recommended for treatment. Treatment rationale and course were discussed with Lindsey,

and she indicated her willingness to engage in the necessary behaviors that this treatment would

entail. Following is a description of the course of therapy, the outcomes achieved, and a three-

year follow up after the cessation of services.

4. Treatment:

4.1 Session 1 (2.25 hours)

The first session began with a check-in with Lindsey and review of her symptom ratings

on the ASI-3 (on which she scored 34 during this session). She indicated that when answering

the ASI items she endorsed levels of concerns she had about body sensations that could occur

during vomiting (as instructed). Lindsey stated that earlier in the week she experienced a panic

attack, which she attributed to no longer avoiding thinking or talking about vomiting. She

indicated that she had taken Rolaids one evening, and following the panic attack she ate crackers,

drank a Sprite, took Pepto Bismal and put a cold washcloth on her face and chest to help distract.

The role of safety behaviors in maintaining her fear and preventing her from knowing what

would happen if she discontinued use of these behaviors was reviewed. Again, rationale for

exposure therapy and what treatment entailed was discussed. Additionally, a fear hierarchy was

developed to guide the remainder of treatment (see Table 1 and note that actual vomiting, the

highest rated stimulus on the hierarchy, was the eventual goal of treatment).

Exposure exercises began during this first session with Lindsey watching a number of

vomiting scenes on a computer. These scenes were viewed in a graded manner beginning with a

more benignly rated video of college students purposefully consuming gallon of milk and

knowingly causing themselves to vomit. Over the protracted course of this first session (and

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Exposure Therapy for Emetophobia 12

assigned as homework) Lindsey engaged in exposure to more seemingly distressful vomiting

experiences (i.e., video of a sick woman on a bathroom floor who was projectile vomiting).

Initially, Lindsey’s anxiety was rated at a 6 (out of 10) in orientation to the most benign stimulus,

a rating which subsequently decreased with each viewing. After watching the first clip three

times, her anxiety never was rated higher than a three for the remaining clips (including new

scenes of projectile vomiting). Thus an effective pattern of within and between trial habituation

was achieved, and these initial, in-situ exposure exercises were deemed to be successful.

In order to continue to capitalize on this success, as well as to provide context for

generalization of eventual treatment gains, Lindsey worked with her therapists to select

exposures from her hierarchy to complete for homework. She agreed to watch different vomit

scenes from YouTube each day for 30 minutes, with the expectation of selecting new videos that

systematically increased in terms of distressing sounds and images for each subsequent exposure.

Additionally, she agreed to cook and eat chicken at home without overcooking the chicken, and

she also agreed to separately overeat during a meal. Lindsey also asserted she would discontinue

her use of safety behaviors when experiencing any sensations in her stomach. The agenda for the

following session was discussed where the plan was to meet at a local restaurant, order medium

rare burgers, overeat, and then take a brisk walk. Limits of confidentiality were discussed in

terms of meeting and completing exposures in public, and Lindsey explicitly agreed to this in-

vivo meeting.

4.2 Session 2 (3 hours)

Lindsey presented to a local area restaurant for the second session two weeks after

session 1. She stated that she had not experienced any panic attacks in the past two weeks.

Additionally, she indicated that she had given up the use of antacids, crackers, and 7-Up when

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Exposure Therapy for Emetophobia 13

feeling queasy; however, she clarified that she had not felt queasy in the past two weeks. Lindsey

stated that she had been watching the vomit clips as instructed, but that she did not do so every

day. Her rationale for less frequent exposure was that she no longer experienced a reaction to the

clips and found them more boring and senseless than anxiety or disgust provoking. She said that

she did not complete the homework of undercooking chicken and eating it at home, but that she

would do so before the next session in one week’s time. During this session both Lindsey and her

therapists ordered medium rare burgers with french-fries, which they proceeded to consume until

feeling uncomfortably full. After taking each bite, Lindsey was noted to look at the pink color of

her hamburger and either make a disgusted face or talk about how she would never have thought

she would do this for fear of becoming sick.

After eating Lindsey and her therapists went on a brisk walk over a nearby pedestrian

bridge in an attempt to induce queasy feelings in Lindsey’s stomach. Initially during the walk

Lindsey stated she felt uneasy and wanted to stop, but quickly reframed her statements to

indicate that she realized that she had been avoiding activities (such as exercise even when not

directly after eating) for no real reason. This realization was reinforced, and Lindsey continued to

engage in the exposure exercise, which persisted to such a point that the therapists also

experienced queasiness. At the termination of this session Lindsey agreed that the next session

would focus on modeling and practicing behaviors associated with vomiting (e.g., kneeling by

the toilet) and practicing gagging.

Additionally, Lindsey continued to express and exhibit motivation to progress to

eventually vomiting herself. She stated that it continued to be difficult to even think about herself

vomiting, but also that she understands and “knows” that she needs to engage in the behavior in

order to overcome this fear. For homework, Lindsey agreed to continue watching clips of

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Exposure Therapy for Emetophobia 14

vomiting each day, with her selection of stimuli being contingent on finding videos that did elicit

sufficient levels of fear to make these exposure exercises useful. Additionally, she agreed to

complete the task of preparing undercooked chicken and eating this at home.

4.3 Session 3 (1.5 hours)

Lindsey presented for session stating that her anxiety was increasing as the intention to

engage in physically vomiting became more imminent. She said that in the past week she

completed the homework of preparing and consuming home cooked chicken- without

purposefully overcooking it. . She remarked that the chicken turned out well, and that she

learned that if you handle chicken appropriately, you can cook it at home and not become sick.

Lindsey also said she continued to watch clips of people vomiting and noticed that “the anxiety

wasn’t there” despite making attempts to increase the salience and difficulty of these stimuli

daily. Lindsey stated that she was beginning to do activities that she never thought she would

have been able to do such as eating greatly undercooked hamburgers, preparing chicken, and

eating a meal and then exercising.

Following this initial review, a new hierarchy of exposures was created (listed in order of

exposure progression): 1) seeing the modeling of and practicing “fake” vomiting; 2) watching

others vomit to study their sensations and how they react (i.e., do they choke, are they concerned

about dying, what happens to them following vomiting?); 3) vomiting with someone around to

offer comfort; and 4) vomiting alone.

The in-session exposure exercise was to both watch and practice “fake vomiting.” In

order to accomplish this, both Lindsey and the female therapist went to a women’s restroom

located in the clinic building. First the therapist modeled fake vomiting by sitting in front of a

toilet making gagging noises. Lindsey kneeled in front of the toilet and practiced this as well.

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Exposure Therapy for Emetophobia 15

Next, the therapist put “fake vomit” (a concoction of diced tomatoes in water) in her mouth,

knelt in front of the toilet, and spit this concoction into the toilet to simulate the texture in the

mouth and sounds of vomiting into the toilet. Lindsey followed the therapist in acting as if she

were vomiting and indicated she was experiencing little anxiety. The only time Lindsey indicated

any anxiety was 1) when she asked the therapist if modeling this would make the therapist vomit

(which the therapist replied that it could), and 2) after having the tomato concoction in her mouth

and feeling some of it in her throat. Lindsey remarked that this exposure was not as anxiety

provoking as she might have anticipated, stating that she knew this was not real and she was just

practicing.

Her original hierarchy was reviewed for the purpose of reinforcing her success, and she

stated directly that she was surprised she had even been able to proceed as far as she had. She

voiced concern that when she needs to vomit she may “freak out” or have a panic attack and pass

out. The therapist encouraged this to happen in session and reviewed the course and treatment of

panic as well as revisited the rationale for exposure treatment. For homework, Lindsey agreed to

practice fake vomiting with increasingly disgusting concoctions each day and to continue to

abstain from the use of any safety behaviors. The plan for the next session was to watch the

therapists vomit and study their reactions to this.

4.4 Session 4 (1.5 hours)

The next session was two weeks later following a cancellation by Lindsey. During the

initial check-in, Lindsey reported that over the past two weeks she had been working on her

homework of practicing fake vomiting. This included using mashed up avocados, tomatoes, and

olives as a fake vomit concoction and acting out vomiting in her home toilet (similar to what was

modeled for her during session 3). She stated that during these experiences, the “vomiting” never

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Exposure Therapy for Emetophobia 16

felt real, and that she did not experience an urge to vomit. Lindsey also stated that due to medical

complications, she recently discovered that she could no longer take birth control pills. She

mentioned that her cognitive interpretation of this led to fears about the possibility of becoming

pregnant, which in turn increased her thoughts and fears about vomiting. Despite these increased

fears, Lindsey articulated a desire to do more than what was planned for this session, and

indicated that she may be able to engage in vomiting herself.

The agenda for the current session was thus revised, and Lindsey was encouraged to first

watch the two therapists vomit with the intention of subsequently attempting to vomit herself.

Lindsey articulated her nervousness and concern for the therapists’ well-being prior to the

beginning of behavioral modeling. Her concerns were not allayed, and she was thus cognitively

primed for heightened anxiety when she watched both therapists proceed to vomit. During the

vomiting, Lindsey asked how the vomiting felt, and if the therapists were concerned about

choking or dying. The therapists genuinely responded with one articulating that following the

large breakfast she ate in preparation for this session, the vomiting actually made her feel more

comfortable. When asked if she were willing to try to vomit, Lindsey stated that she would try,

but added that she did not eat much for breakfast despite her therapists’ advice to do so.

Although she attempted to vomit by intermittently gagging herself for approximately 20 minutes,

she was unable to vomit. Lindsey indicated disbelief in that she had both watched the therapists

vomit and also made an attempt to do so herself. Additionally, she remarked that she “knows”

vomiting would not be so bad and articulated that she needs to “just vomit.” After discussion, it

was decided that next session would be devoted to her vomiting and she would prepare by eating

a large breakfast beforehand. For homework, Lindsey stated she would try to vomit at home with

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Exposure Therapy for Emetophobia 17

a full stomach of water to prepare for the next session where the plan would be for her to vomit

with a full stomach of “more chunky vomit.”

4.5 Session 5 (1 hour)

Lindsey presented for session stating that she “did not come prepared.” She said that

following the last session she had intrusive and obsessive thoughts surrounding her vomiting.

She indicated that she did not complete her homework of attempting to vomit at home, and

likewise did not eat any breakfast to help prepare her for vomiting during this session. After

discussion and assessment of her motivation, she agreed that the only step remaining in this

treatment was for her to vomit and if she were unwilling to do so, it would not make sense to

continue with exposures that were no longer creating distress. Lindsey agreed that for the next

session she would complete the homework prior to session or she would cancel. She stated

understanding that engaging in vomiting in session was necessary to overcome her fear, and that

until she was willing to progress towards this in therapy she should cancel sessions. To help

promote success, a very specific homework plan was discussed and created with Lindsey. She

agreed that prior to the next scheduled session (on a Friday) she would 1) practice “fake”

vomiting a watery substance (e.g. water or soup) at least once before Thursday evening, 2)

review the video tape of therapists vomiting during session (and her attempt at vomiting) daily,

and 3) on the morning of session 9:30 (at her selected restaurant) eat a ham and cheese croissant,

hashbrown and orange juice just prior to the 10:00 scheduled session. She stated that she would

review the plan with her mother to increase her accountability and added she would also bring a

toothbrush to session. She appeared to have a renewed motivation and confidence in her ability

to face this fear when she left the session.

4.6 Client call to Psychologist

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Lindsey later called the supervising psychologist, and was seemingly very excited. She

stated that following the session where she presented unprepared, she felt bad about her

equivocation in terms of therapeutic commitment, which prompted her to go immediately home

and vomit. She said that this was a freeing experience for her, and that she was able to separately

proceed to vomit with her husband present and later her mother. Lindsey stated that she no

longer understood why she thought vomiting was so dangerous, and said that since she faced her

fear and had no additional concerns about vomiting, that she no longer needed treatment.

Lindsey said that she would be willing to be contacted in the future for follow up, but given her

success and resultant change in appraisal concerning the future experience of vomiting, did not

feel she needed additional therapy.

5. Follow up

When contacted via telephone in February of 2010, Lindsey stated she was excited to

hear from her former therapist. She said that she was now married, and that she and her husband

were actively trying to conceive. Lindsey stated that she continued to have some residual fears

about vomiting, but not to the extent that it prevented her from engaging in the activities she

once avoided (i.e., exercising, trying to become pregnant, and cooking meat at home). She also

added that she was now able to console her husband when he was sick and vomiting, which

coincidentally had occurred in the month prior to this telephone contact. Lindsey agreed to

complete any follow up questionnaires that were sent and mentioned that she continued to

appreciate the services provided to her by the psychology clinic.

With her verbal consent Lindsey was thus sent a follow-up packet (via U.S. mail)

containing the ASI-3, OCI-R, and BVS, as well as a free response questionnaire (assessing use of

safety behaviors, current anxiety related to vomiting, current medications, and thoughts about

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Exposure Therapy for Emetophobia 19

potentially becoming pregnant). Specifically, from the free response questionnaire, Lindsey

stated that she no longer engages in safety behaviors (such as keeping antacids, avoiding cooking

meat), and is no longer taking any prescription medication. Additionally, she reported that she no

longer felt much anxiety in general about vomiting, but did experience some if she were in fact

“sick to my stomach.” When asked if she avoided anything (such as foods or activities) for fear it

would cause her to vomit, she responded “nothing.” In addition, her response to the question,

“Do you believe that if you were to vomit you would choke and die?” was that she was mostly

concerned with choking and not being able to breathe leading to a panic attack, but that she no

longer had concerns about dying as a result of vomiting.

Furthermore, it can be noted that Lindsey’s scores on the ASI-3, OCI-R and BVS

improved from pretreatment to follow up (see Table 2). The decrease in ASI-3 scores from

pretreatment to follow up was dramatic. As mentioned previously, Lindsey stated that her initial

responses on the ASI-3 were related to the sensations she was concerned about if she were to

vomit. As reflected in this measure, her fear of arousal sensations related to vomiting decreased,

which was a predicted and likely effect from treatment using exposure. By repeatedly having the

opportunity to confront these uncomfortable internal sensations related to vomiting and

subsequently learning that these sensations did not produce the catastrophic effects imagined,

Lindsey was no longer adversely affected by fear of her sensations. OCI-R scores also decreased

over the three year period. Although not the focus of treatment, it appeared (based on the OCI-R

responses) that over the three year period, some of her avoidance and checking behaviors, also

decreased. Similarly, in regard to the scores on the BVS, the changes in the two scales

demonstrated that although Lindsey continued to be attentive to her bodily sensations, she no

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longer was sensitive to such changes and did not equate them to negative meaning related to

vomiting.

Functionally, Lindsey’s improvements included the ability to expose herself to previously

feared and avoided situations (e.g., caring for husband when he was sick), and her active

attempts to become pregnant (i.e., the reason she initially presented to treatment). Although she

continued to report experiencing some residual fear regarding vomiting, she indicated that this no

longer interfered with her life or prevented her from engaging in any desired activity. As such, it

was ascertained that she no longer met diagnostic criteria for this unique specific phobia.

6. Discussion

The present paper outlined the assessment and course of exposure therapy for an

individual presenting with emetophobia. The observed change in symptoms and behaviors

immediately following therapy, as well as gains maintained at three-year follow up, provide

promising initial evidence for the effectiveness of exposure based treatment for this low base-

rate condition. Results from this case study demonstrated that by employing exposure therapy,

the client not only eliminated her avoidance of feared situations, but she also evidenced sustained

cognitive change and a reduction in hypervigilance to internal physiological symptoms

previously associated with catastrophic fear, avoidance and distress. From this case example,

using an individual’s fear hierarchy with the inclusion of vomiting proved to be not only

acceptable, but the most helpful for the client to treat the underlying fear. In terms of this

particular client’s catastrophic cognitions related to the different steps of the exposure hierarchy,

it was deemed by both therapists as well as client that having the client vomit, as opposed to just

imagining herself vomit, or seeing others vomit was an essential component for her treatment.

Additionally, the client reported understanding that completing this step in her exposure

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hierarchy was safe, tolerable and effective in treatment. The progression through this particular

hierarchy (including actual vomiting), exemplified the idiographic adaptation of nomothetically

established behavioral principles of exposure for treatment of a specific phobia. More

specifically, this case study illustrated the feasibility of the using in vivo exposure therapy as

treatment for emetophobia.

Moreover, this case study demonstrated through psychoeducation (related to both the

disorder as well as exposure treatment) patients may actually be very willing to engage in

exposure therapy. A previous concern outlined in Lipsitz et al.’s (2001) study suggested

individuals (responding from an emotophobia website) reported a reluctance to engage in

exposure-based treatments. However, these individuals were completing an online survey, were

not evaluated for true emetophobia diagnosis, and were likely not provided with the rationale and

evidence to support the use of exposure therapy in phobias. As such, this may not be a true

representation of emetophobics’ views on exposure therapy if provided with treatment rationale

and the cognitive-behavioral conceptualization of emetophobia. Moreover, it is likely that when

presented as an option to treatment seeking individuals, exposure therapy could be considered as

not only an acceptable, and tolerable treatment, but a preferred treatment of emetophobia as was

seen in this case illustration (and given the broad support for behavioral approaches more

generally and the absence of any evidence for a more effective form of treatment specific to this

condition).

One limitation of this report was the use of self-report measures that were not specific to

emetophobia symptoms (i.e., ASI-3, BVS). Although not available at the time of treatment, two

measures related to symptoms of emetophobia have recently been developed: the Emetophobia

Questionnaire (Boschen, Veale, & Ellison, unpublished) and the Specific Phobia of Vomiting

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Inventory (SPOVI; Veale et al., in press). Initial psychometric support has been found for use of

the SPOVI in clinical populations and may provide researchers with a measure to further

conceptualize and better understand specific symptoms and clinical presentations of this

disorder. Additionally, this report represents a single subject case study regarding exposure

therapy as treatment for an individual with emetophobia. The importance of replication of

successful treatment using exposure therapy in multiple trials, ideally involving randomized

group designs to the extent possible, is essential to further evaluate effectiveness and efficacy.

Moreover, it is likely that future studies could more thoroughly capture information in numerous

clinically relevant domains in the context of conducting randomized efficacy trials.

In summary, the case presented here provides continued support for the CBT

conceptualization of emetophobia and the use of exposure therapy as an effective treatment with

gains maintained at three-year follow-up. By systematically moving up through the patient’s fear

hierarchy, treatment was able to target her idiographic experience of this specific phobia. The

feasibility and integral nature of exposure exercises designed to make her vomit (as opposed to

think about or view someone else vomiting) were also demonstrated. Similar to other behavioral

treatment for more common specific phobias, it appeared that the theoretical mechanism of

exposure’s effectiveness (i.e., emotional processing; Foa & Kozack, 1986) was supported.

Additionally, it can be reiterated that emetophobia is an under-researched and undertreated

specific phobia. It is important for continued research in order to have a better conceptual

understand of this disorder as well to assess the efficacy of treatments and refine their usage in

this relatively uncommon, but clinically and academically interesting, disorder.

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Figure 1.

Cognitive- Behavioral Model of Emetophobia

MALADAPTIVE BELIEFS

Vomiting could cause me to suffocate or choke to death

Stomach queasiness will cause me to vomit

INCREASED PERCEPTION OF POTENTIAL THREATS

Likely to notice any stomach queasiness

CATASTROPHIC THOUGHTS

I might vomit and die

ANXIETY/PANIC

SAFETY BEHAVIORS

Take antacids, eat crackers, drink 7up, distract self

Avoid: alcohol, overeating, undercooked meat,

exercise, amusement park rides

INREASED ATTENTION TOWARD POTENTIAL THREATS

How my stomach is feeling

Fight or Flight

Response

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Table 1.

Outcome Measures at Pretreatment and 3 year Follow-Up

Measure Pretreatment 3 year Follow-Up

ASI-3 34 2

OCI-R 12 4

BVS

-attention to internal body sensations 10 8

-sensitivity in changes in internal body 8 3

sensations

Note. ASI-3= Anxiety Sensitivity Index-3; OCI-R= Obsessive Compulsive Inventory, Revised;

BVS= Body Vigilance Scale.

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Table 2.

Hierarchy of Emetophobia-related situations

Activity SUDS RANK

Note. SUDS = subjective units of distress

Eating a medium- rare burger 2 8

Watching video clips of people vomiting 4 7

Drinking Alcohol 5 6

Overeating 6 5

Cooking and eating chicken 6 4

Running Immediately after a big meal 7 3

Watching/listening to others vomit 7.5 2

Vomiting 10 1

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